The University of North Carolina at Chapel Hill
Office of Human Resources
AUTHORIZATION FOR BACKGROUND CHECK
TO BE COMPLETED BY THE CANDIDATE/APPOINTEE
As part of the University’s comprehensive security efforts and to ensure a safer environment for our students, staff and visitors,
University policy requires that a background check be conducted for all staff and faculty, unpaid volunteers, interns, visiting scholars and
any other individuals engaged by campus departments in programs that serve or involve contact with minors.
Background checks related to the protection of minors served by University programs must be accomplished at least annually for those
University staff, faculty, or volunteers who have ongoing involvement in such programs regardless of any previous background checks
that may have been conducted.
NOTE: Your social security number is required for the background check consistent with University policy. If you choose not to disclose
your social security number, you will not be considered for employment.
LEGAL NAME - FIRST
MIDDLE
MAIDEN
LAST
SOCIAL SECURITY NUMBER (SSN)
DATE OF BIRTH
SEX
RACE
INTERNATIONAL APPLICANTS - Check here if you do not have a Social Security Number:
)
NAME HISTORY
(
Please list all names by which you have been known, along with the dates each name was used (if more space is needed
attach additional pages):
ADDRESS HISTORY
CURRENT ADDRESS (street, city, state, zip):
PERMANENT ADDRESS (if different from current address)
If address is not in the U.S. address, include country):
PRIMARY PHONE NUMBER (XXX-XXX-XXXX)
If you have lived or worked outside of North Carolina, please list all of those locations within the United States and the dates
you lived or worked there since the age of 18 (if more space is needed attach additional pages):
NAME
DATES (FROM/TO)
COUNTY
STATE
EDUCATIONAL
CREDENTIALS
CITY
NAME
Please indicate your highest level of education completed (or degree in progress if you are a Post Doc candidate with
all but dissertation):
DATES MM/YY
SCHOOL NAME, CITY AND STATE
MAJOR FIELD OF STUDY
DEGREE TYPE
PROFESSIONAL
LICENSURE
DATES (FROM/TO)
DATES (FROM/TO)
Please indicate the professional licensure and/or certifications that you possess:
LICENSE NUMBER
ISSUING AUTHORITY
DATE ISSUED
EXPIRATION DATE
Continued on next page
Rev (12/10/2013)
UNC-Chapel Hill - Equal Opportunity Employer
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The University of North Carolina at Chapel Hill
Office of Human Resources
AUTHORIZATION FOR BACKGROUND CHECK
TO BE COMPLETED BY THE CANDIDATE/APPOINTEE
DRIVIER LICENSE
FIRST
MIDDLE
NORTH CAROLINA
DRIVERS LICENSE #
DRIVING CONVICTIONS
LAST
EXPIRATION DATE
I have held an out-of-State driver’s license that has been valid within the last 12 months. If the
answer is yes, provide the information below.
OUT OF STATE
DRIVERS LICENSE #
Yes
No
DATE
Yes
CRIMINAL CONVICTIONS
MAIDEN
DATE
Rev (12/10/2013)
ISSUING STATE
Have you ever been convicted of a minor driving infraction? If yes, list below the county, state, and
date of the conviction and crime/offense for which you were convicted. Note: State law allows the
applicant to not refer to any arrest, charge, or conviction that has been expunged. If more space is
needed attach additional pages.
LOCATION (county and state)
No
YES
NO
TRAFFIC VIOLATION
Have you ever been convicted of an unlawful offense other than a minor driving infraction? If yes, list
below the county, state, and date of the conviction and crime/offense for which you were convicted.
Note: State law allows the applicant to not refer to any arrest, charge, or conviction that has been
expunged. If more space is needed attach additional pages.
LOCATION (county and state)
CRIME/OFFENSE
UNC-Chapel Hill - Equal Opportunity Employer
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The University of North Carolina at Chapel Hill
Office of Human Resources
AUTHORIZATION FOR BACKGROUND CHECK
TO BE COMPLETED BY THE CANDIDATE/APPOINTEE
DISCLOSURE REGARDING BACKGROUND INVESTIGATION
The University of North Carolina at Chapel Hill may obtain information about you for employment purposes from a third party
consumer reporting agency. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which
may include information about your character, general reputation, personal characteristics, and/or mode of living and which can
involve personal interviews with sources such as your neighbors, friends, or associates. These reports may contain information
regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of
your education or employment history, or other background checks. You have the right, upon written request made within a
reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.
Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to
applicants for employment is an investigation into your education and/or employment history conducted by Castle Branch, Inc.,
1845 Sir Tyler Drive, Wilmington, NC 28405, 888-723-4263, or another outside organization. The scope of this notice and
authorization is all-encompassing, however, allowing the University to obtain from any outside organization all manner of
consumer reports and investigative consumer reports now and throughout the course of your employment to the extent permitted
by law. As a result, you should carefully consider whether to exercise your right to request disclosure of the nature and scope of
any investigative consumer report.
New York and Maine applicants or employees only: You have the right to inspect and receive a copy of any investigative
consumer report requested by the Company by contacting the consumer reporting agency identified above directly. You may also
contact the Company to request the name, address, and telephone number of the nearest unit of the consumer reporting agency
designated to handle inquiries, which the Company shall provide within 5 days.
New York applicants or employees only: Upon request, you will be informed whether or not a consumer report was requested by
the Company, and if such report was requested, informed of the name and address of the consumer reporting agency that
furnished the report. By signing below, you also acknowledge receipt of Article 23-A of the New York Correction Law.
Oregon applicants or employees only: Information describing your rights under federal and Oregon law regarding consumer
identity theft protection, the storage and disposal of your credit information, and remedies available to you should you suspect or
find that the Company has not maintained secured records is available to you upon request.
Washington State applicants or employees only: You also have the right to request from the consumer reporting agency a written
summary of your rights and remedies under the Washington Fair Credit Reporting Act.
ACKNOWLEDGEMENT AND AUTHORIZATION
I hereby certify that all information I have provided on this Authorization is true and complete to the best of my knowledge and
belief. I understand that my Authorization indicates my consent to the University to verify any information contained in this
Authorization, by obtaining a consumer report for employment purposes from a Consumer Reporting Agency. I understand
that by admitting to a conviction for any unlawful offense, I will not be automatically disqualified from consideration for
employment, unpaid appointment or for other opportunities where I might have contact with minors. I understand that false or
misleading information or documentation, or an omission or failure to include all relevant information, may result in action up to
and including not being employed, appointed, affiliated or terminated if hired, and/or criminal prosecution. I understand the
University complies with State law and is required to terminate me if false or misleading information is given in order to meet
the requirements for the position for which I am hired.
______________________________________________________
Candidate/Appointee Signature
Rev (12/10/2013)
_______________________________
Date
UNC-Chapel Hill - Equal Opportunity Employer
Page 3 of 4
The University of North Carolina at Chapel Hill
Office of Human Resources
AUTHORIZATION FOR BACKGROUND CHECK
FOR INTERNAL CAMPUS DEPARTMENT USE ONLY
FORM SUBMISSION:
 For SPA Permanent employees, Unpaid Volunteers, Interns, and Visiting Scholars - Send this form to your Employment
Consultant in the Office of Human Resources.
 For Faculty - Send this form to your Dean’s Office.
 For EPA Non-Faculty, SPA/EPA Temps and all other persons - Send this form to:
Background Unit/Office of Human Resources, CB#1045
Phone: 919-962-9768 or 919-843-4413
Fax: 919-962-4279
ALL FIELDS BELOW ARE REQUIRED AND MUST BE COMPLETED. INCOMPLETE FORMS WILL NOT BE ACCEPTED.
FIRST
MIDDLE
LAST
SSN (Last 4 Digits Only)
xxx-xx-
MOTOR VEHICLE HISTORY
Indicate if driving a motor vehicle (State-owned or personal/other) is required to perform assigned
duties. *If yes, you must submit a legible copy of the candidate’s driver’s license with this form.
Please indicate type of vehicle that will be driven (choose all that apply):
CREDENTIALS VERIFICATION
Please indicate if the position requires verification of education/professional licensure.
FOREIGN DEGREE VERIFICATION
Indicate if the candidate possesses a foreign degree. If yes, the hiring department is responsible
for completing degree verification and sending a copy to the Background Check unit within
90 days of hire.
FACULTY
EPA NON-FACULTY
EPA TEMP
SPA PERMANENT
SPA TEMP
UNC STUDENT
(IF REQ’D)
POSITION/ APPOINTMENT TYPE
(please indicate all that apply):
POST DOC
POST DOC (ABD)
VOLUNTEER
INTERN
VISITING SCHOLAR
YES*
NO
STATE-OWNED
PERSONAL/OTHER
DEGREE
YES
NO
LICENSE
YES
NO
YES
NO
CONTACT WITH MINORS
CDC SELECT AGENT
ANNUAL RE-CHECK (IF REQ’D)
CREDENTIALS CHECK ONLY
DRIVING CHECK ONLY
OTHER _____________________
POSITION/APPOINTMENT TITLE:
POS# (if applicable):
DEPT. HR REPRESENTATIVE NAME:
HR REPRESENTATIVE CONTACT #:
DEPARTMENT NAME:
DEPARTMENT #:
CAMPUS BOX #:
ACCOUNT # FOR FEES:
OHR EMPLOYMENT CONSULTANT:
Shaundria Williams, MPA
919-843-8782
School of Info. & Lib. Science
3701
3360
3-37011
Vickie Suggs (SPA Temps), Toby Hedgepeth (SPA Perm), Carl Farmer (EPA N/F)
FOR INTERNAL OFFICE OF HUMAN RESOURCES USE ONLY
FINAL RESULTS:
CLEAR
NOT CLEAR
CRIMINAL CONVICTIONS
DATE RECEIVED:
PID #
REVIEW REQ’D:
Yes
No
DATE RETURNED:
CHECKS COMPLETED:
VALID DRIVER’S LICENSE
COURT SEARCH
CASTLE BRANCH
AOC
NC DL CHECK
OUT OF STATE DL
EPLS/OIG
NO CS RESULTS
SEX OFFENDER
AMOUNT DUE: ________
Yes
No
Possible Match
Reported on Background Authorization?
Yes
No
INITIALS: _____ FILE #: ___________
Yes
Yes
No
Possible Match
Reported on Background Authorization?
Yes
No
DEGREE VERIFIED
Charge made to the listed account
Rev (12/10/2013)
No
DRIVING CONVICTIONS
Yes
UNC-Chapel Hill - Equal Opportunity Employer
No
LICENSE(S) VERIFIED
Yes
No
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